News for Noses

BROBSON LUTZ, M.D.

Symtpoms that are nothing to sniff at
If you think allergies are a stuffed-up nose and a tickle in the throat, stop thinking and keep reading.
“Ninety percent of people in New Orleans who think they have nasal allergies are wrong. They actually have vasomotor rhinitis, fueled by sensitivity to changes in temperature, humidity or barometric pressure,” says Dr. Michael Ellis, a prominent ear, nose and throat specialist who also performs facial plastic surgery.
This New Orleans-born doctor has the most informative patient handouts I have ever read. His passion for making congested noses and tickled throats well again begins with making a proper diagnosis. If you think the main use of the nose is as a prop for glasses, you have not talked to Ellis.
Nose parts
Most of the nose is made of gristle-like cartilage, which can fracture or become deformed. Air can sneak into the lungs from the mouth, but the nose is nature’s intended gateway. The oxygen-exchange membranes in the lungs need a continuous source of warm, humidified and filtered air.
Look at an old man on the street and you are likely to see two holes or nostrils with some hairs sticking out. For a properly groomed New Orleanian, you have to look inside the nose to see these hairs, which filter out some of the larger circulating pollen and dirt particles.
The nasal septum separates the two nostrils and the nasal passages. A deviated septum disrupts the normal flow of air. The nasal cavities connect with the back of the throat and are separated from the inside of your mouth by the hard and soft palates. The respiratory mucosa from just inside the nose all the way down to the lungs is lined with fluid-producing glands.
“There are two main kinds of glands in the nose, sinuses, throat and lungs – mucus glands and serous or ‘watery’ glands,” says Ellis, visibly excited to talk about mucus.
“Mucus is good. It acts like flypaper to capture inhaled dust and debris. The watery secretions, on the other hand, warm and humidify the air before it gets to the lungs.
“Adults generate about a quart of mucus every 24 hours. Mucus quantity and texture remains constant. The watery glands, however, can vary their output dramatically. Excessive watery secretions occur with colds or allergy attacks. This is what causes a nose to run, but you don’t feel these thin secretions in your throat. Reduced watery secretions lead to thicker mucus, the real perpetrator of the postnasal drip sensation.”
Postnasal drip and congestion – they are not the same
Go to a drugstore with a postnasal drip or nasal congestion and odds are that you will walk out with antihistamines, decongestants or both.
Last November I wrote the following in this column: “Treatment options for treating coughs caused by postnasal drips include prescription nasal sprays, antihistamines and combinations of decongestants and antihistamines.”
Shortly after, Ellis shouted by e-mail:
“HATE TO DISAGREE WITH MY GOOD FRIEND, BROBSON, BUT POSTNASAL DRIP OR PHLEGM IS DUE TO TOO LITTLE WATERY SECRETIONS – NOT AN EXCESS. ANTIHISTAMINES COMPOUND THE PROBLEM. THIS IS A COMMON MEDICATION ERROR.”
Ellis added that the optimal treatment for a postnasal drip includes expectorants, increased water intake and steam. A decongestant can help unstop a clogged nose, but decongestants also aggravate dryness and should always be used with expectorants.
According to Ellis, the only use for an antihistamine is for the sneezy, runny and itchy nose.
“The No. 1 complaint in my office is ‘I have bad allergies and need medication,’ ” says Ellis. “It is necessary to ferret out the symptoms and make a proper diagnosis. I always ask, ‘What do you mean by allergy? What are your symptoms?’ ”
“Patients self-diagnosed with nasal allergies are seldom right. The actual problem is usually thick secretions and difficulty breathing through the nose. A stopped-up nose and thick mucus are not allergic symptoms. It is vasomotor rhinitis.”
Real allergic rhinitis is much less common than vasomotor rhinitis in New Orleans, according to Ellis. True nasal allergies are fueled by histamine releases, causing the nose to itch and run. Recurrent sneezing off and on all day is another histamine-induced phenomena. Dust mites, cat dander and pollens are common triggers.
Anything that causes dehydration decreases watery secretions -- fever, working outside in hot weather and decreased oral intake. But the most common culprit decreasing watery secretions is dry air. The air inside airplanes is obviously dry. But the air we breathe inside with air-conditioning and heating is almost as bad. And many medications also decrease watery secretions. According to Ellis, common offenders include “fluid pills, antihistamines, tranquilizers and decongestants.”
Understanding how vasomotor rhinitis works is the most important step in controlling the symptoms. A reduction in watery secretions causes the nasal mucus to thicken. Desiccated nasal membranes lead to decreased watery secretions, which cause mucus to thicken. Sensory nerves in the throat translate thick mucus into the sensation we know as a postnasal drip.
Some experts postulate that persons subject to vasomotor rhinitis have an imbalance in the nerve supply to their inner nasal membranes. Overly dry air irritates and desiccates these nasal membranes causing the small blood vessels in the area to enlarge or dilate. Swelling and engorgement of these nasal blood vessels leads to the sensation of swelling of the nasal obstruction.
Triggers that activate vasomotor rhinitis symptoms include dry air, low humidity, strong odors, many aerosol sprays, cigarette smoke, and a change in temperature, humidity or barometric pressure.
The best drug treatment for vasomotor rhinitis is an expectorant to help increase watery secretions by diluting thick mucus (see box). Ellis advises his patients to avoid dry air, antihistamines and long-term decongestants.
To increase the intranasal humidity he goes low-tech and advises breathing through hot, wet, washcloths frequently during day and hot showers or a steam bath. He tells his patients to sleep with a vaporizer or ultrasonic, fine-mist humidifier at bedside.
Indiscriminate allergy testing complicates the diagnosis. False positives tests are common. Just because a person tests “positive” for a particular allergen does not mean that an allergy to that substance is responsible for the person’s nasal congestion. Some unfortunate folks have both allergic and vasomotor problems.
Other irritants are over-the-counter drops or sprays such as Afrin and Neo-Synephrine. “Your nose can get hooked on Afrin,” Ellis says. “I tell persons who use Afrin regularly that they may not be addicts, but their noses are.” •